Level of Need Assessment Form
Facility Fax:
Dear Medical Professional:
Our office has received a request for non-emergency medical transportation for a Wisconsin Medicaid or BadgerCare Plus member. This form will be used to determine the patient’s most appropriate mode of transportation based on his or her functional abilities and limitations. Your role in completing this form is critical to ensure patients receive the correct mode of transportation. Please fill out this Level of Need Assessment (LON) form legibly and completely,providing any supporting information as needed.
Patient Info / First Name:
/ Last Name:
/ Date of Birth:
ForwardHealth ID #: / Phone #: / Trip #:
Address:
/ City: / State:
/ Zip:
Living Arrange-ments / Lives alone or with family/friends Group home Residential rehab facility
Comments:
Number of external steps at residence:
Physical Abilities and Equipment / Can patient ambulate independently? Yes No
Does patient use any of the following assistive devices?
Walker Crutches Cane Portable Oxygen Service Animal Manual Wheelchair Electric Wheelchair
Does patient require assistance of trained personnel for safety? Yes No
Can patient self propel in wheelchair? Yes No / Can patient self-transfer from wheelchair into vehicle?Yes No
Do environmental factors like heat or cold affect the patient’s mobility? Yes (must explain):
No
Has there been a decline in functionality? Yes (must explain): No
Cognitive Abilities / Does the patient have problems with any of the following? If yes, circle a rating for each category, with 1 being mild impairment and 5 being severe impairment.
Alertness No Yes 1 2 3 4 5
Memory Issues No Yes 1 2 3 4 5
Confusion No Yes 1 2 3 4 5 / Mental & Behavioral Health / Explain mental/behavioral health limitations that would affect the member’s transportation:
Able to remove self from unsafe situation? Yes No
Sensory Abilities / Vision / Cataracts Legally blindComments:
Speech& Hearing / Deaf? Yes No / Able to communicate needs? Yes No
Diagnosis and Transport Info / Diagnosiscode and description that supports transportation limitations (MUST PROVIDE, if applicable): / Diagnosis is:
Permanent
Temporary Through (date):
Recent Hospitalizations/Surgeries (MUST PROVIDE):
Additional Comments:
Medical Professional Info / Printed name and credentials: / Phone #:
Signature:
Questions? Please call MTM, Inc.’s. Facility Support Line at (866) 907-1497
Please fax this completed form to: 1-866-686-7618, ATTN: Care Management
This form must be receivedno less than two business days prior to the appointment to ensure the appropriate mode of transportation.